No abstract

A 62-year-old man came to the emergency department reporting mild chest pain that was similar to pain he had experienced 18 years before when he suffered a myocardial infarction. An electrocardiogram and cardiac biomarkers did not show any signs of an acute coronary syndrome; he was therefore admitted to the cardiology department for further studies. A chest X-ray revealed two round structures that were initially interpreted as calcified nodules (Panel A). Stress echocardiography was undertaken, which demonstrated no evidence of myocardial ischemia but did indicate a coarctation of the distal aortic isthmus with a peak to peak gradient of 8 mmHg. To confirm this finding, computed tomographic angiography (CTA; Panel B) and magnetic resonance angiography (MRA; Panel C) were done, showing a significant aortic coarctation. There was an extensive collateral circulation, which was one of the reasons for the low pressure gradient. The CTA also demonstrated a calcified, 30-mm bilobed pseudoaneurysm with its origin in a branch of the left subclavian artery, corresponding to the calcified structure on the chest X-ray (arrows). Additional tests were performed in order to exclude related vascular complications, including binocular indirect ophthalmoscopy and magnetic resonance angiography of the vessels of the neck and head, both of which were unremarkable. At the time of diagnosis, the patient refused any kind of intervention. He continued on beta-blockers and additional antihypertensive drugs and is being followed by cardiologists and vascular surgeons. The ACC/AHA Guidelines 1 recommend treating aortic coarctation when the translesional gradient is > 20 mmHg or when there is evidence of significant collateral flow at the time of diagnosis in older patients. The endovascular-first approach is now accepted in adults with aortic coarctation, as it is a safe technique with a low rate of complications. 2,3 Panel C

A 72-year-old man, with no medical history of interest, was referred to our clinic for evaluation of tiredness and heaviness in the upper limbs, which was somewhat more pronounced on the left side and was of approximately 6 months in evolution and slow in onset. He denied any association with effort, but reported a certain worsening during the summer and improvement with the local application of cold compresses. Physical examination revealed the presence of multiple, superficial, soft tumors along the venous pathways of bilateral arms, which appeared to be partially thrombosed venous dilatations. Arterial examination of the upper limbs was completely normal, and there were no significant findings on vascular examination of the lower limbs. Magnetic resonance angiography showed ectasia of the deep and superficial veins of the upper limbs, later confirmed by computer tomography. The images correspond to the upper left limb, with diffuse, partially thrombosed ectasia (Panel A) of the deep (Panel B) and superficial (Panel C) venous system, with permeability and without ectasia of the arterial axis (Panel D). The main deep veins, innominate trunk and superior vena cava were patent without any ectasia.Philipp Bockenheimer described Bockenheimer's syndrome, or genuine diffuse phlebectasia, for the first time in 1907 1 in a 52-year-old patient with clinical symptoms similar to those of our patient. Later reported cases mainly corresponded to pediatric patients. 2 The clinical signs vary according to the patient, and the severity of symptoms is conditioned by the size of the phlebectasia, generally in the upper limbs as in the original case, although it has also been described in the lower limbs and genitals. 3 A histological examination shows veins with reduced smooth muscle and elastin in the walls, with thrombosis and